Examinations of Organizations and Providers; Reports of Examinations; Payment of Expenses of Examinations

  1. Law
  2. Georgia Code
  3. Insurance
  4. Health Maintenance Organizations
  5. Examinations of Organizations and Providers; Reports of Examinations; Payment of Expenses of Examinations

Checkout our iOS App for a better way to browser and research.

  1. Whenever the Commissioner of Insurance shall deem it expedient, but not less than once every three years, he or his designee shall visit and examine the transactions, accounts, financial records, and documents of any health maintenance organization and of the providers with whom such organization has contracts, agreements, or other arrangements pursuant to its health benefits plan; and in connection with such examination the Commissioner of Insurance shall also have the authority to conduct an examination into the market conduct of the health maintenance organization.
  2. Whenever the commissioner of community health shall deem it expedient, but not less than once every five years, he or she or his or her designee shall visit and examine all matters relating to the quality of health care services of any health maintenance organization and providers with whom the organization has contracts, agreements, or other arrangements pursuant to its health benefits plan as often as he or she deems it necessary for the protection of the interests of the people of this state; provided, however, that health maintenance organizations meeting the requirements of subsection (b.1) of Code Section 33-21-3 shall not be subject to examination by the commissioner of community health.
  3. Every health maintenance organization, its officers, employees, representatives, and providers shall produce and make freely accessible to the Commissioner of Insurance or the commissioner of community health the accounts, records, documents, and files in its possession or control relating to the subject of the examination. The officers, employees, representatives, and providers shall facilitate such examination and aid the examiners as far as it is in their power in making the examination.
  4. The Commissioner or his or her designee shall make a full written report of each examination made by him or her containing only facts ascertained from the accounts, records, and documents examined and from the sworn testimony of witnesses.
  5. The report shall be certified by the Commissioner of Insurance or by the examiner in charge of the examination and, when so certified and after filing as provided in subsection (f) of this Code section, shall be admissible in evidence in any proceeding brought by the Commissioner against the health maintenance organization examined or any officer or agent of the health maintenance organization and shall be prima-facie evidence of the facts stated in such report.
  6. The Commissioner of Insurance shall furnish a copy of the proposed report to the health maintenance organization examined not less than 20 days prior to filing the report. If the health maintenance organization so requests in writing within such 20 day period or any longer period as the Commissioner may grant, the Commissioner shall grant a hearing with respect to the report and shall not file the report until after the hearing and such modifications have been made in the report as the Commissioner may deem proper.
  7. The Commissioner of Insurance may withhold from public inspection the report of any examination or investigation for so long as he deems it to be in the public interest or necessary to protect the health maintenance organization examined from unwarranted injury.
  8. After the report has been filed, the Commissioner of Insurance may publish the report or the results of such report in one or more newspapers published in this state if he should deem it to be in the public interest.
  9. The health maintenance organization so examined shall pay, at the direction of the Commissioner of Insurance, all the actual travel and living expenses connected with the examination. When the examination is made by an examiner who is not a regular employee of the Department of Insurance, the health maintenance organization examined shall pay the proper charges for the services of the examiner and his assistants in an amount approved by the Commissioner. A consolidated account for the examination shall be filed by the examiner with the Commissioner. No health maintenance organization or other entity shall pay and no examiner shall accept any additional emolument on account of any examination. When the examination is conducted in whole or in part by regular salaried employees of the department, payment for the services and proper expenses shall be made by the health maintenance organization examined to the Commissioner; and such payment shall be deposited with the Office of the State Treasurer.

(Code 1933, § 56-3616, enacted by Ga. L. 1979, p. 1148, § 1; Ga. L. 1982, p. 3, § 33; Ga. L. 1992, p. 6, § 33; Ga. L. 1993, p. 1402, § 18; Ga. L. 2004, p. 493, § 4; Ga. L. 2009, p. 453, § 1-6/HB 228; Ga. L. 2010, p. 863, § 2/SB 296; Ga. L. 2019, p. 337, § 1-93/SB 132; Ga. L. 2019, p. 386, § 1/SB 133.)

The 2019 amendments. The first 2019 amendment, effective July 1, 2019, substituted "Department of Insurance" for "Insurance Department" in the second sentence of subsection (i). The second 2019 amendment, effective July 1, 2019, in subsection (d), substituted "The Commissioner or his or her designee" for "The Commissioner of Insurance or his designee" at the beginning, inserted "or her" in the middle, and substituted "witnesses" for "witness" at the end.


Download our app to see the most-to-date content.